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-- <br />SAN JOAQUIN COUNTY RECEIVED, � 11 <br />ENVIRONMENTAL HEALTH DEPARTMENT k J 6 09 <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fac: (209) 468-3433 Web: www.sigov.org/eh EHEALTH <br />N PERMITESERVICNTAL <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 35 days of receipt of the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($122). <br />For this certification to be complete the operator of the site must include: <br />• A statement documenting what corrective actions were taken or will be taken for each violation <br />• Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: 1 �I 0 / <br />Facility Address: <br />I certify under penalty of law that: <br />Inspected By: <br />EPA ID#: CA L 00 0 3L4 Q <br />EPI 4_rA-- 0 0 366y o <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurateX and complete: <br />> Photos Paperwork Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aw re are significant penalties for submitting false information, including the <br />possibili of and/or imprisonment for known violations. (HSC 2519 1) <br />Name: Title: Off*// <br />Signature: C) �G Date: O �/ <br />EHD 22-02-005 Rev 08/10 %aS s`evl (f l I <br />fc,( <br />0\-A V, O\ -'JV\ QivYq <br />